Surname:

Forenames (Mother & Father)

Whats your address?


Telephone number:
(Include Area Code)

Work number:
(Include Area Code)

Mobile number:
(Include Area Code)

Emergency contact number:
(Include Area Code)

Email address:

Fax number:
(Include Area Code)

Childrens' Names & Date of Birth:

Religion of family: Please indicte if you are
observant of your religion:

Nationality of family:


What is the main language spoken in the home by the family?:
(Au Pairs are only allowed (by law) to go to a family where English is spoken at Home –
if a girl is placed with a family, and subsequently we are informed that English
is not being spoken at home – the girl will be removed and no refund will be applicable)

Fathers Occupation:

Mothers Occupation:

No. of adults living in the home:

Pets:

Language school:

Public transport:

Childrens school:
(Distance from home)

Is your home:
Rural
Semi Rural
Suburban
Town/City

Name of nearest station:

Do you need a driver? Yes No

Do you require a non smoker?
Essential
Smoke outside
Don't mind

Do any members of your family smoke? Yes No

Family hobbies, etc:

Details of Family's home:

Will the Au Pair have her own bedroom? Yes No

Will the Au Pair have her own bathroom? Yes No

Will the Au Pair have her own TV? Yes No

Other i.e. Hi-Fi, use of car, bicycle:

Would you consider a male Au Pair? Yes No

Where did you hear about the agency from?

The Agency require Single Parent Fathers to
provide 2 references. (These can be sent at a later date)

Duties and Responsibilities of your Au Pair:

Do you have any other domestic help in the home?
Please give details:

Have you ever had an Au Pair before? Yes No

How much Pocket Money do you pay your Au Pair? £

How many hours per week will you ask your Au Pair to work? hrs

Please give details of free time:

Please select your choice of: AU PAIR AU PAIR +

If you require a Mother's Help or Nanny please tick box:

Date required to commence:

Length of Stay:

Do you have any objections to the agency passing your telephone number
to other Au Pairs in your area, thereby allowing new Au Pairs to
the area to have friends? Yes No

It is VERY IMPORTANT that the Agency is informed of any details that will assist them in finding the correct au pair for the family. (Please include any dietary needs, medical condition, degree of religious observance, family origins, etc)

I understand Au Pairs are not qualified in Childcare, and therefore they should not be given sole charge of children under the age of 2. I understand that The Agency cannot be held responsible for any loss, damage or injury caused to persons or property by my Au Pair.

Name:

Date:

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